09090014 _ CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1514 POPPY WAY CONTRACTOR:TBD-TO BE PERMIT NO:09090014
DETERMINED
NER'S NA,VIE: MICHAEL& EMMY HO DATE ISSUED:09/02/2009
uvVNER'S PHONE: 4083099763 PHONE NO:
A-- LICENSED CONTRACTOR'S DECLARATION 1�
c�
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class_ Lic.#_ 2>0 f— r
Gl MECH RESIDEN AL COMMERCIAL
Contractor/ 2 - Dated
1 hereby affirm th�Ia�m��ce d under he provision/s of apter 9 JOB DESCRIPTION: POOL DEMO
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
I hereby affirm under Penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labot Code,for the
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$4000
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this
APN Number:366101 13.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that 1 have reaj this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct I agree to comply with all city and county ordinance:,and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
building construction.and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION.
indetanify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the
-
granting of this permit. Addis ally,the applicant understands and will comply Issued Date:
with all non-po t urce re ations per the Cupertino Municipal Code,Section
9 18.
RE-ROOFS:
ia:ur Date- /_0-7
_ a All roofs shall be inspected prior to any roofing material being installed. if a roof is
installed without first obtaining an inspection,1 agree to remove all new materials for
inspection.
Ll OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
1 hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1,as owner of the proper y,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Busin,,ss&Professions Code)
I,as owner of the propcny,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I will
1 hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(x)should 1 store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air ality Management District
performance of the work for which this permit is issued. will maintain compliance with the Cu rtino icipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sectio 505 5 3,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this CJ
permit is issued. Owner or authorized agent: Date:
1 certify that in the performance of the work for which this permit is issued,I shall
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,1 CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
I certify that I have read this application and state that the above information is
correct. 1 agree to comply with all city and county ordinances and state laws relating
tip building construction,and hereby authorize representatives of this city to enter
the above mentioned property for inspection purposes.(We)agree to save
..,unify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
u
costs and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
graving of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Profes:,ional
9.13.
Signature ___ Date__
Community Development
' 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
7UPE�TINO
Building Department
JOB ADDRESS: PERMIT #
f �q Ab&lf &Ay rwAallmolo o 0 f��
OWNER'S NAME: / PHONE # c_q
GENERAL CONTRACT R: AX #
I am not using any subcontractors- 14'�o
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36610113 . 00
DATE ISSUED. . . . . . . : 09/02/2009
RECEIPT #. . . . . . . . . : BS000008593
REFERENCE ID # . . . : 09090014
SITE ADDRESS . . . . . : 1514 POPPY WAY
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : MICHAEL & EMMY HO
ADDRESS . . . . . . . . . . : 1514 POPPY WAY
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-5307
RECEIVED FROM . . . . : GARRET STEVENSEN
CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096
COMPANY . . . . . . . . . . : TBD - TO BE DETERMINED
ADDRESS . . . . . . . . . .
CITY/STATE/ZIP . . . : ,
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 0 . 00 1 . 00 0 . 00 1 . 00 0 . 00
1BSEISMICR VALUATION 0 . 00 0 . 50 0. 00 0 . 50 0 . 00
1DEMOPRE SQUARE FEET 0 . 00 490 . 00 0 . 00 490 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 491 . 50 0 . 00 491 . 50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 491 .50 1724
---------------
TOTAL RECEIPT 491 .50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
704 DEMO
CITY OF CUPERTINO
.,,. ~ , DEMO
CUPEkTINO PERMIT APPLICATION FORM
6
APN# Date: / Q
Building Address:
Mailing Address (if different from building address):
Owner's Name: Phone:
Wo I A c �(4 CL <� Oiq y0i-
Contractor: Phone
ISC_A^ ,.� �vr1�r^aWIA.�' Fax:
Contractor License #: ` ��`3
Cupertino Business License #:
Phone:
Contact: 41- 6 g S —
Fax:
Residential Sq Footage 1 Commercial ❑ Sq Footage
Job Description:
L �J o
Valuation:
OOD �'--
Project Size: Express Standard ❑ Large ❑ Major ❑
Please complete relevant portions of the Green Building Checklist & attach it to the application
or if applicable, include on the plan set & the sheet index.
Quantity Fee ID Fee Description Fee Group Permit Type
1DEMORES Demo-Residential B 1SFDWL-DEM
1DEMOPRES Pool Demo Residential B 1SFP00L-DEM_
/ 1BCBSC Cal Bldg Standards B ALL PERMIT
Commission Fee TYPES
t 1BSEISMICRE Seismic Residential B
Revised 01/07/09